Based on observation, interview and record review it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include but not limited to:

During an unannounced site visit on 12/13/2022, Compliance Specialist (CS) observed multiple staff members not wearing masks and two staff members wearing surgical masks.

During separate interviews, Staff #1-Staff #3 (S1-S3) stated:

*They currently had one COVID + resident in the building

*We didn't know we needed an N95.

A review of the facilitys's Community COVID-19 Infection Control Response updtaed 02/28/2022 stated N95's "must be worn during outbreak status by all staff in all departments. "

These findings were reviewed with S1 on 12/13/2022.

Plan of Correction: In-services to occur beginning 12/13/22 on masking and infection control protocols.